Colorado Clinics for the Foot and Ankle Dr. Erik Ouderkirk, DPM Dr. Corey Bess, DPM

Transcription

1 Date: Colorado Clinics for the Foot and Ankle Dr. Erik Ouderkirk, DPM Dr. Corey Bess, DPM 2373 Central Park Blvd. Ste. 201 Denver CO N Huron St. Ste. 20 Northglenn CO East Wildcat Reserve Pkwy Ste. 200 Highlands Ranch CO New Patient Packet Patient Name: Date of Birth: Age: Last First MI Home Address: City, State: Zip: May we leave a message? Home Phone #: Yes No Work Phone#: Yes No Cell Phone #: Yes No Primary Language: Race: Ethnicity: Do you have a legal guardian or power of attorney? Yes No If yes, Name: Relationship: Phone #: Emergency Contact: Primary Care Doctor: Pharmacy & Location: Phone#: Phone#: Phone#: Who is responsible for payment/ relationship to patient? Address: City, State: Zip: Who referred you to us? Insurance information Primary Insurance Company Name: Secondary Insurance Company Name:

2 Please list all medications you are currently taking (Including Over-The-Counter Meds, and herbal supplements): Name Dose How often do you take Please list all prior surgeries Type of Surgery Date Please list all prior hospitalizations (other than for surgery) Social History Marital Status: Single Married Partnered Separated Widowed Race: American Indian or Alaska Native Asian Black/ African American White Other Use of alcohol: Never No longer use History of alcohol abuse Current use type Rare Occasional Moderate Daily Use of tobacco: Never Quit Smoke Packs per day for years Use of recreational drugs: Never Quit How long ago Type Employer: Occupation: How much are you on your feet at work? 10% 25% 50% 75% 100% Do others depend on you for their care? Children Ages: Pet(s) Elderly or disabled family member Other:

3 Exercise: Never Rare Occasional Weekly Several times a week Daily Type of exercise: Family History Do you have a family history of: Diabetes type 1 or 2 Cancer Heart Disease High blood pressure Stroke Coronary artery disease Thyroid disease Rheumatoid arthritis Other: Your Medical History Allergies: Tape Latex Shellfish Iodine None Known of Have you ever had and of the following? Acid Reflux Y N Fibromyalgia Y N Neuropathy Y N Anemia Y N Gout Y N Open Sores Y N Arthritis Y N Heart Attack Y N Pneumonia Y N Back Trouble Y N Heart Disease/ Failure Y N Polio Y N Bladder Infections Y N Hepatitis Y N Rheumatic Fever Y N Abnormal Bleeding Y N HIV+ / AIDS Y N Sickle Cell Disease Y N Blood Clots Y N High Blood Pressure Y N Skin Disorder Y N Blood Transfusion Y N Kidney Disease Y N Sleep Apnea Y N Bronchitis Y N Liver Disease Y N Stomach Ulcers Y N Cancer Y N Low Blood Pressure Y N Stroke Y N Diabetes 1 or 2 (circle) Y N Migraines/ headaches Y N Thyroid disease Y N Mitral Valve Prolapse Y N Tuberculosis Y N Emphysema Y N Other:

4 Current Problem What brings you to the office today? : Where is the pain located? Please mark on the pictures below. How long ago did this problem first start? Days / Weeks / Months / Years Did you pain or problem begin All of a sudden or Gradually over time How would you describe your pain? No pain Sharp Dull Aching Burning Radiating Itching Stabbing Other How would you rate your pain on a scale from 1-10? (Please circle) (No pain) (worst pain possible) Since the time your pain or problem began, has it Stayed the same Become worse Improved What makes your pain a problem feel worse? Walking Standing Daily activities Resting Dress shoes High heels Flat shoes Any closed toe shoe Running Other: What makes your pain or problems feel better? What treatments have you had for this problem? How has this problem affected your lifestyle or ability to work?

5 Was this problem caused by an injury? No Yes (Describe) If yes, was it a work related injury? Yes N Please read the following page for information on how we protect you privacy as well as your financial and other obligations while receiving care from us. Patient Financial Policy Your understanding of our financial policies is an essential element of your care and treatment. If you have any questions, please discuss them with our front office staff or supervisor. As our patient, you are responsible for all authorizations/referrals needed to seek treatment in this office. Unless other arrangements have been made in advance by you, or your health insurance carrier, payment for office services are due at the time of service. We will accept VISA, MasterCard, Discover, cash or check. Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment. We have made prior arrangements with certain insurers and other health plans to accept an assignment of benefits. We will bill those plans with which we have an agreement and will only require you to pay the co-pay/co-insurance/deductible. If you have insurance coverage with a plan with which we do not have a prior agreement, we will prepare and send the claim for you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, all charges for your care and treatment are due at the time of service. All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be "not covered," or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized services or referrals; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered. You must inform the office of all-insurance changes and authorization/referral requirements. In the event the office is not informed, you will be responsible for any charges denied. For most services provided in the hospital, we will bill your health plan. Any balance due is your responsibility. There are certain elective surgical procedures for which we require pre-payment. You will be informed in advance if your procedure is one of those. In that event, payment will be due one week prior to the surgery. Past due accounts are subject to collection proceedings. All costs incurred including, but not limited to, collection fees, attorney fees and court fees shall be your responsibility in addition to the balance due this office.

6 There is a service fee of $25.00 for all returned checks. Your insurance company does not cover this fee. Appointment cancellation without 24 hour notice may be subject to a $25 fee. There is $25.00 fee for NO SHOW appointments after first time Balances over 90 days without arrangements are sent to collections Release of Health Information I acknowledge that David Erik Ouderkirk, DPM, PC will, when required, release medical information or copies from my medical record from my date of admission through my date of discharge to insurance companies, third party payers or authorized paying agent, or claims review organizations in order to process a claim for payment in my behalf. This information may be disseminated to comply with the requirement of any Professional Review Organization, Accreditation, Utilization Review and Medical Audit. I also acknowledge that my information may be released to providers that may be involved in my continuity of care. I also acknowledge that David Erik Ouderkirk, DPM, PC may request information concerning my care, condition, and treatment from providers including healthcare facilities and consultants. To the best of my knowledge I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status. Print name of Patient, Parent or Guardian If other than patient, Relationship to patient Signature Date

7 Signature of Doctor/ Staff Date